Posts Tagged Gamification

[Systematic Review] Exoskeletons With Virtual Reality, Augmented Reality, and Gamification for Stroke Patients’ Rehabilitation: Systematic Review – Full Text


Background: Robot-assisted therapy has become a promising technology in the field of rehabilitation for poststroke patients with motor disorders. Motivation during the rehabilitation process is a top priority for most stroke survivors. With current advancements in technology there has been the introduction of virtual reality (VR), augmented reality (AR), customizable games, or a combination thereof, that aid robotic therapy in retaining, or increasing the interests of, patients so they keep performing their exercises. However, there are gaps in the evidence regarding the transition from clinical rehabilitation to home-based therapy which calls for an updated synthesis of the literature that showcases this trend. The present review proposes a categorization of these studies according to technologies used, and details research in both upper limb and lower limb applications.

Objective: The goal of this work was to review the practices and technologies implemented in the rehabilitation of poststroke patients. It aims to assess the effectiveness of exoskeleton robotics in conjunction with any of the three technologies (VR, AR, or gamification) in improving activity and participation in poststroke survivors.

Methods: A systematic search of the literature on exoskeleton robotics applied with any of the three technologies of interest (VR, AR, or gamification) was performed in the following databases: MEDLINE, EMBASE, Science Direct & The Cochrane Library. Exoskeleton-based studies that did not include any VR, AR or gamification elements were excluded, but publications from the years 2010 to 2017 were included. Results in the form of improvements in the patients’ condition were also recorded and taken into consideration in determining the effectiveness of any of the therapies on the patients.

Results: Thirty studies were identified based on the inclusion criteria, and this included randomized controlled trials as well as exploratory research pieces. There were a total of about 385 participants across the various studies. The use of technologies such as VR-, AR-, or gamification-based exoskeletons could fill the transition from the clinic to a home-based setting. Our analysis showed that there were general improvements in the motor function of patients using the novel interfacing techniques with exoskeletons. This categorization of studies helps with understanding the scope of rehabilitation therapies that can be successfully arranged for home-based rehabilitation.

Conclusions: Future studies are necessary to explore various types of customizable games required to retain or increase the motivation of patients going through the individual therapies.



Stroke refers to a sudden, often catastrophic neurological event that can lead to long-term adult disability. The American Heart Association (AHA) is responsible for providing up-to-date statistics related to heart disease and stroke. According to Benjamin et al [1], the AHA released a 2017 statistics report on heart disease and stroke that stated that approximately 795,000 stroke episodes occur in the US each year. With current advancements in medical technology there has been a decrease in the rate of stroke incidents, but it can still cause paralysis and muscle weakness. Such impairments can result in motor deficits that disturb a stroke survivor’s capacity to live independently.

There are several reasons for stroke occurrence, which could be related to an increased risk of a collection of symptoms caused by disorders affecting the brain (eg, dementia) [2]. Various rehabilitation techniques have been used in the area of rehabilitation-based interactive technology to assist patients in recovering from impairments, and those techniques come under the umbrella of conventional therapy, exoskeleton or robot-aided therapy, virtual reality (VR) or augmented reality (AR) therapy, games-based therapy, or a combination of any of these. These forms of therapy can be done either in the clinic or in an in-home setting. In addition to these, there is a new technology known as telerehabilitation [3] that leverages the use of VR in home settings by providing patients access to real-time rehabilitation services through the internet while they sit at home.

One of the most effective techniques is robot-aided therapy, which has been gradually increasing in use primarily because patients may consider traditional rehabilitation therapy to be tiring and exhaustive. This may decrease their motivation and cohesion to the treatment, thus resulting in only minor improvement in the health of poststroke patients [46]. Various experimental evidence suggests that robot-assisted (or exoskeleton) rehabilitation has been effective in keeping patients motivated and interested in treatment for both upper or lower limb impairments [7,8]. With advancements in technology, there has also been an uptake of VR, AR, and Gamification for the purposes of rehabilitation [9], along with robotic rehabilitation [10,11], primarily to increase engagement, immersion and motivation on behalf of the patient. Both Colombo et al and Alankus et al [12,13] concluded and showed the positive effect of exoskeleton robots and games in poststroke rehabilitation. Wearable devices such as exoskeletons can also relay real-time feedback for any VR-based interactions [14].

Apart from these studies, Housman et al [15] showed user satisfaction survey results in which 90% of participants agreed to the fact that robot- or games-assisted therapies were less confusing, and improvements were very easy to track compared to traditional or conventional therapies. Further, it is thought that gamification can increase repetition, engagement, and range of care within the context of rehabilitation [16,17]. Games are not only useful for the field of rehabilitation, but they are also considered to be highly impactful and relevant in other medical and health fields. Russoniello et al [18] conducted a randomized controlled trial (RCT) study in which the effects of video games on stress-related disorders were tested, with the conclusion being that games were beneficial for their prevention and treatment. In another study, children who had cerebral palsy made use of a game (EyeToy) which was able to improve their upper extremity functions over time [19].



Continue —->  JRAT – Exoskeletons With Virtual Reality, Augmented Reality, and Gamification for Stroke Patients’ Rehabilitation: Systematic Review | Mubin | JMIR Rehabilitation and Assistive Technologies

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[Abstract] Virtual Reality Environment for the Cognitive Rehabilitation of Stroke Patients


We present ongoing work to develop a virtual reality environment for the cognitive rehabilitation of patients as a part of their recovery from a stroke. A stroke causes damage to the brain and problem solving, memory and task sequencing are commonly affected. The brain can recover to some extent, however, and stroke patients have to relearn to carry out activities of daily learning. We have created an application called VIRTUE to enable such activities to be practiced using immersive virtual reality. Gamification techniques enhance the motivation of patients such as by making the level of difficulty of a task increase over time. The design and implementation of VIRTUE is presented together with the results of a small acceptability study.

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[ARTICLE] Benefits and challenges with gamified multi-media physiotherapy case studies: a mixed method study – Full Text



The use of gamification in higher education context has become popular in recent years with one aim of enhancing learning motivation, yet, it is unknown how physiotherapy students perceive gamified education experience. Using gamification together with multi-media patient case studies, this study explored whether and how gamified education motivated physiotherapy students’ learning. It also investigated how other factors such as class design and mechanics affected gamified experience.


Six case studies in the subject Neurological Physiotherapy were transformed from paper-based cases to multi-media cases built by iSpring suite 8.1. Simulated, real or animated clients were used. Gamification mechanics such as leaderboards, scoring and prioritisation were embedded in the case studies. These gamified case studies were used in classes with Year-3 students enrolled in this subject. After taking these classes, 10 students participated in two focus groups and 32 students responded to a survey to share their experiences and perceptions on this pedagogy.


Results showed that students perceived gamified education as motivating since this satisfied their competence and social needs and enhanced their self-efficacy. In addition, authentic patient videos, class activities that allowed conflict resolution and reflection, and the use of leaderboards were enablers in this gamified experience.


Future gamified education in physiotherapy can provide authentic experience through class designs and gamification mechanics to foster learning motivation. A suggested mapping of gamified lessons for physiotherapy education is provided based on the results of this study.


Learning is an inherently human activity that involves many complex active and interactive processes. Motivation appears to be a key driver to both initial and ongoing learning, as well as improved learning outcomes [1234]. Gamification, or the use of game elements in non-game contexts [5], promotes achievement, challenge, goal, competition and collaboration to learning [6], which in turn motivates learners [7]. Gamification is thought to enhance motivation and engagement through three levels of processes: cognitive, psychological/emotional and social [89]. At the cognitive level, learners experience processes such as problem-solving and decision-making [10]. At the psychological/emotional level, learners’ positive emotions (e.g. feeling competent) with certain experiences would wire into their memories to enhance further learning of similar experiences [1112]. At the social level, interactions with other learners facilitate knowledge constructions [13]. Gamified education should be structured to promote these processes.

To promote the aforementioned processes, better conceptualisations of gamification are needed. Gamification mechanics are often classified by reward or process-tracking types; namely leaderboards, badges, points (or scores), feedback and prizes [79]. Some educational gamification systems use one type of mechanics while others use a mix-and-match approach. Pedersen and Poulsen [9] found that feedback and points showed an increase in positive outcomes in terms of learning motivations, while other mechanics warrant further investigations. In addition, it is important to differentiate between game-based learning, gamification and serious game. Game-based learning is the use of games (digital or non-digital) as learning tools [14], while gamification does not necessarily include a game but embed game elements (such as competitions) in learning tasks [5]. The term serious game is sometimes used interchangeably with game-based learning as it applies to any game with a purpose other than pleasure; here learning fits into this rationale [81516]. The focus of this study is on gamification rather than game-based learning and serious game.

Gamification has been applied across different disciplines in higher education, such as computer science, mathematics, language and health education [171819]. Currently, there is a lack of literature describing or studying gamification in physiotherapy education. In a recent systematic review on gamification in health care education by Wang, DeMaria [20], only two out of 48 reviewed studies included physiotherapy students as participants. This paucity warrants investigation in the use of gamification in physiotherapy education given its reported benefits on learning.[…]


Continue —>  Benefits and challenges with gamified multi-media physiotherapy case studies: a mixed method study | Archives of Physiotherapy | Full Text

Fig. 1 Title pages of the three gamified virtual patient cases


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[Conference Proceedings] Rhythmic Entrainment for Hand Rehabilitation Using the Leap Motion Controller – Full Text PDF


Millions of individuals around the world suffer from motor impairment or disability, yet effective, engaging, and cost-effective therapeutic solutions are still lacking. In this work, we propose a game for hand rehabilitation that leverages the therapeutic aspects of music for motor rehabilitation, incorporates the power of gamification to improve adherence to medical treatment, and uses the versatility of devices such as the Leap Motion Controller to track users’ movements. The main characteristics of the game as well as future research directions are outlined.

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via Rhythmic Entrainment for Hand Rehabilitation Using the Leap Motion Controller | Kat Agres

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[Review] Gamified In-Home Rehabilitation for Stroke Survivors: Analytical Review – Full Text DOC file


A stroke is a life-changing event that may end up as a disability, with repercussions on the patient’s quality of life. Stroke rehabilitation therapies are helpful to regain some of the patient’s lost functionality. However, in practice stroke patients may suffer from a gradual loss of motivation. Gamified systems are used to increase user motivation, hence, gamified elements have been implemented into stroke rehabilitation therapies in order to improve patients’ engagement and adherence. This review work focuses on selecting and analyzing developed and validated gamified stroke rehabilitation systems published between 2009 and 2017 to identify the most important features of these systems. After extensive research, 32 articles have met the selection criteria, resulting in a total of 28 unique works. The works were analyzed and a total of 20 features were identified. The features are explained, making emphasis on the works that implement them extensively. Finally, a classification of features based on objectives is proposed, which was used to identify the relationships between features and implementation gaps. It was found that there is a tendency to develop low-cost solutions as in-home therapy systems; to include automated features; provide a diversity of games and use of simple interaction devices. This review allowed the definition of the opportunities for future research direction such as systems addressing the three rehabilitation areas; data analytics to make decisions; motivational content identification based on automatic engagement detection and emotion recognition; and alert systems for patient´s safety.

  1. Introduction

Brain stroke is a life-changing disease that can have fatal consequences. Stroke survivors may end up with long-term disabilities. These disabilities will depend on the damaged part of the brain and the body functions related to it. Older adults are the population with the highest risk of suffering a stroke and ending up with a disability. This makes of stroke the leading cause of adult disability worldwide [1-4].

Stroke rehabilitation therapy has proven to be useful in helping the patient to regain some of his lost functionality [5-8]. In traditional rehabilitation programs, when the rehabilitation in the hospital is completed, the patients return to their homes, where they should continue with more rehabilitation activities. However, the patient’s adherence is reduced at home. The two main causes for this are: the lack of available resources and tools to sustain training for longer periods; and, a diminishing motivation as repetitive exercises are perceived as tedious and boring [9-12]. Gamified rehabilitation systems have proven to be useful to improve motor and cognitive function and additionally as a tool to motivate patients to adhere to the therapy programme [13-22].

This study focuses on gamified systems dedicated for stroke patients’ upper limb rehabilitation for in-home use. The objectives of this study are: 1) provide a literature review of the developed and tested gamified systems for in-home stroke rehabilitation, between 2009 and 2017; 2) identify and explain the most used features of these systems; 3) provide a simple way to classify the features, in order to identify the relationships between them and the gaps of their implementations. A total of 32 articles have met the selection criteria, which resulted in a total of 28 unique works. From analysis of these studies, a total of 20 features were identified. The remaining of this paper is structured as follows. Section 2 describes the methodology used to find the reviewed works and the database to be used, as well as the selection criteria applied to select research works. Section 3 presents the results of the analysis, with the emphasis on the importance of each feature and the works that implemented them to higher extents. An analytical point of view is discussed in Section 4, where an objective-based classification is proposed, the relationships between the features are presented and additionally, the gaps in the current systems are identified. Finally, Section 5 is dedicated for the conclusion and the future research perspectives.[…]

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[Abstract+References] Motion-Based Serious Games for Hand Assistive Rehabilitation


Cerebral Palsy, trauma, and strokes are common causes for the loss of hand movements and the decrease in muscle strength for both children and adults. Improving fine motor skills usually involves the synchronization of wrists and fingers by performing appropriate tasks and activities. This demo introduces a novel patient-centered framework for the gamification of hand therapies in order to facilitate and encourage the rehabilitation process. This framework consists of an adaptive therapy-driven 3D environment augmented with our motion-based natural user interface. An intelligent game generator is developed, which translates the patient’s gestures into navigational movements with therapy-driven goals, while adapting the level of difficulty based on the patient profile and real-time performance. A comprehensive evaluation and clinical-based assessments were conducted in a local children disability center, and highlights of the results are presented.



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[Abstract] Gamification of Hand Rehabilitation Process Using Virtual Reality Tools: Using Leap Motion for Hand Rehabilitation


Nowadays virtual reality (VR) technology give us the considerable opportunities to develop new methods to supplement traditional physiotherapy with sustain beneficial quantity and quality of rehabilitation. VR tools, like Leap motion have received great attention in the recent few years because of their immeasurable applications, whish include gaming, robotics, education, medicine etc. In this paper we present a game for hand rehabilitation using the Leap Motion controller. The main idea of gamification of hand rehabilitation is to help develop the muscle tonus and increase precision in gestures using the opportunities that VR offer by making the rehabilitation process more effective and motivating for patients.

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Source: Gamification of Hand Rehabilitation Process Using Virtual Reality Tools: Using Leap Motion for Hand Rehabilitation – IEEE Xplore Document

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[Abstract+References] Ubiquitous gamification framework for stroke rehabilitation treatment based on the web service


Every year a large number of people survives from the stroke. To overcome the muscular rigidity, the survivors should participate the rehabilitation program regularly. Above all things, the motivation of the survivors easily collapses and hinder the participating the rehabilitation program. As a consequence, finding a good motivator for individual survivors is an important task for the caregivers and the therapists. This paper utilizes an individualized game for a motivator and proposes a ubiquitous gamification framework for stroke rehabilitation using web-services. The framework provides a formal interface to embrace individualized games and devices and motivates the survivors to participate the rehabilitation process in daily life.


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Ren, Y., Wu, Y. N., Yang, C. Y., Xu, T., Harvey, R., and Zhang, L. Q. 2016. Developing a wearable ankle rehabilitation robotic device for in-bed acute stroke rehabilitation. IEEE Trans Neural Syst Rehabil Eng. 99 (2016), 1–1.  [doi>10.1109/TNSRE.2016.2584003]
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Wood, S. R., Murillo, N., Bach-y-Rita, P., Leder, R. S., Marks, J. T., and Page, S. J. 2003. Motivating, Game-Based Stroke Rehabilitation: A Brief Report. Top Stroke Rehabil. 10, 2 (2003), 134–140.  [doi>10.1310/WB09-PFYJ-7XRN-RU6W]
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Cho, K. H., Lee, K. J., and Song, C. H. 2012. Virtual-Reality Balance Training with a Video-Game System Improves Dynamic Balance in Chronic Stroke Patients. Tohoku J. Exp. Med. 228, 1 (2012), 69–74.  [doi>10.1620/tjem.228.69]
Hondori, H. M., Khademi, M., and Lopes, C.V. 2012. Monitoring intake gestures using sensor fusion (Microsoft Kinect and inertial sensors) for smart home tele-rehab setting. 1st Annual IEEE Healthcare Innovation Conference of the IEEE EMBS. (2012).
Sin, H., and Lee, G. 2013. Additional Virtual Reality Training Using Xbox Kinect in Stroke Survivors with Hemiplegia. Am J Phys Med Rehabil. 92, 10 (2013), 871–880.  [doi>10.1097/PHM.0b013e3182a38e40]
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Lange, B. S., Flynn, S. M., and Rizzo, A. A. 2009. Initial usability assessment of off-the-shelf video game consoles for clinical game-based motor rehabilitation. Phys Ther Rev. 14, 5 (2009), 355–363.  [doi>10.1179/108331909X12488667117258]
Deutsch, J. E., Robbins, D., Morrison, J., and Bowlby, P. G. 2009. Wii-based compared to standard of care balance and mobility rehabilitation for two individuals post-stroke. Virtual Rehabilitation International Conference. (2009), 117–120.  [doi>10.1109/ICVR.2009.5174216]
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Source: Ubiquitous gamification framework for stroke rehabilitation treatment based on the web service

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[WEB SITE] Gaming helps personalized therapy level up – Penn State University

UNIVERSITY PARK, Pa. — Using game features in non-game contexts, computers can learn to build personalized mental- and physical-therapy programs that enhance individual motivation, according to Penn State engineers.

“We want to understand the human and team behaviors that motivate learning to ultimately develop personalized methods of learning instead of the one-size-fits-all approach that is often taken,” said Conrad Tucker, assistant professor of engineering design and industrial engineering.

They seek to use machine learning to train computers to develop personalized mental or physical therapy regimens — for example, to overcome anxiety or recover from a shoulder injury — so many individuals can each use a tailor-made program.

“Using people to individually evaluate others is not efficient or sustainable in time or human resources and does not scale up well to large numbers of people,” said Tucker. “We need to train computers to read individual people. Gamification explores the idea that different people are motivated by different things.”

To begin creating computer models for therapy programs, the researchers tested how to most effectively make the completion of a physical task into a gamified application by incorporating game features like scoring, avatars, challenges and competition.

“We’re exploring here how gamification could be applied to health and wellness by focusing on physically interactive gamified applications,” said Christian Lopez, graduate student in industrial engineering, who helped conduct the tests using a virtual-reality game environment.

Screen from game designed to test features for gamification use in physical and mental therapy. Image: Kimberly Cartier / Penn State

In the virtual-reality tests, researchers asked participants to physically avoid obstacles as they moved through a virtual environment. The game system recorded their actual body positions using motion sensors and then mirrored their movements with an avatar in virtual reality.

Participants had to bend, crouch, raise their arms, and jump to avoid obstacles. The participant successfully avoided a virtual obstacle if no part of their avatar touched the obstacle. If they made contact, the researchers rated the severity of the mistake by how much of the avatar touched the obstacle.

In one of the application designs, participants could earn more points by moving to collect virtual coins, which sometimes made them hit an obstacle.

“As task complexity increases, participants need more motivation to achieve the same level of results,” said Lopez. “No matter how engaging a particular feature is, it needs to move the participant towards completing the objective rather than backtracking or wasting time on a tangential task. Adding more features doesn’t necessarily enhance performance.”

Tucker and Lopez created a predictive algorithm — a mathematical formula to forecast the outcome of an event — that rates the potential usefulness of a game feature. They then tested how well each game feature motivated participants when completing the virtual-reality tasks. They compared their test results to the algorithm’s predictions as a proof of concept and found that the formula correctly anticipated which game features best motivated people in the physically interactive tasks.

The researchers found that gamified applications with a scoring system, the ability to select an avatar, and in-game rewards led to significantly fewer mistakes and higher performance than those with a win-or-lose system, randomized gaming backgrounds and performance-based awards.

Sixty-eight participants tested two designs that differed only by the features used to complete the same set of tasks. Tucker and Lopez published their results in Computers in Human Behavior.

The researchers chose the tested game features from the top-ranked games in the Google Play app store, taking advantage of the features that make the games binge-worthy and re-playable, and then narrowed the selection based on available technology.

Their algorithm next ranked game features by how easily designers could implement them, the physical complexity of using the feature, and the impact of the feature on participant motivation and ability to complete the task. If a game feature is too technologically difficult to incorporate into the game, too physically complex, does not offer enough incentive for added effort or works against the end goal of the game, then the feature has low potential usefulness.

The researchers would also like to use these results to boost workplace performance and personalize virtual-reality classrooms for online education.

“Game culture has already explored and mastered the psychological aspects of games that make them engaging and motivating,” said Tucker. “We want to leverage that knowledge towards the goal of individualized optimization of workplace performance.”

To do this, Tucker and Lopez next want to connect performance with mental state during these gamified physical tasks. Heart rate, electroencephalogram signals and facial expressions will be used as proxies for mood and mental state while completing tasks to connect mood with game features that affect motivation.

The National Science Foundation funded this research.

Source: Gaming helps personalized therapy level up | Penn State University

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[Abstract] Gamification in Physical Therapy: More Than Using Games


The implementation of computer games in physical therapy is motivated by characteristics such as attractiveness, motivation, and engagement, but these do not guarantee the intended therapeutic effect of the interventions. Yet, these characteristics are important variables in physical therapy interventions because they involve reward-related dopaminergic systems in the brain that are known to facilitate learning through long-term potentiation of neural connections. In this perspective we propose a way to apply game design approaches to therapy development by “designing” therapy sessions in such a way as to trigger physical and cognitive behavioral patterns required for treatment and neurological recovery. We also advocate that improving game knowledge among therapists and improving communication between therapists and game designers may lead to a novel avenue in designing applied games with specific therapeutic input, thereby making gamification in therapy a realistic and promising future that may optimize clinical practice.

Source: Gamification in Physical Therapy: More Than Using Games : Pediatric Physical Therapy

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